Abstract: Objectives: To assess the appropriateness, requisition form quality, clinical reasoning ability, and radiation exposure of non-contrast emergency computed tomography (CT) examinations in pediatric patients, and to compare requisition form quality across groups stratified by different levels of appropriateness of examination. Methods: Clinical data, examination requisitions, and radiation dose records of pediatric patients aged < 18 years who underwent non-contrast-enhanced emergency CT at a tertiary hospital between November 1 and December 31, 2025, were prospectively documented for analysis. Scans with incomplete or erroneous information were excluded. Appropriateness of examination was scored from 1 to 9 using the iGuide toolkit, released by the European Society of Radiology. Requisition form quality was graded from A to D based on the Reason for Exam Imaging Reporting and Data System. Reasoning ability of clinicians was calculated as the percentage of CT diagnoses that were consistent with the final clinical diagnoses (range: 0%–100%). Volume CT dose index (CTDI_vol) and dose-length product were documented for all scans. Results: Data from 405 patients with a median age (first and third quartile) of 15.0 (14.0, 16.0) years, were included, and 209 (51.6%) patients were male. Scans were categorized as usually not appropriate, maybe appropriate, usually appropriate, or un-assessable, in 258 (63.7%), 96 (23.7%), 4 (1.0%), and 47 (11.6%) examinations, respectively. Excluding the un-assessable examinations, the median appropriateness score was 3.0 (1.0, 4.0) of a total score of 9.0. The distribution of requisition Grades A to D was 60 (14.8%), 42 (10.4%), 284 (70.1%), and 19 (4.7%), respectively. A small percentage of examination requisitions provided a specific clinical diagnosis (107, 26.4%). An even smaller percentage of requisitions had diagnoses that were consistent with the corresponding CT reports (11, 2.7%). As a result, the clinical reasoning score was 0.0% for the majority of examinations (394, 97.3%). For the 47 un-assessable emergency non-contrast CT scans, the median (first and third quartile) CTDI_vol and DLP were 30.77 (13.49, 51.31) mGy and 642.33 (403.05, 805.29) mGy·cm, respectively. Conclusion: More than 50% of non-contrast-enhanced emergency CT scans in pediatric emergency practice were rated as usually not appropriate, accompanied by sub-standard requisition quality and inadequate clinical reasoning, which may lead to a radiation burden that could be avoided. Clinicians should optimize the appropriateness of pediatric emergency CT referrals to reduce unnecessary radiation exposure.